Iatrogenic aortic root and left main dissection during non-emergency coronary surgery: a solution applicable to heavily calcified coronary arteries†.

Dissection of the left main coronary artery during coronary artery bypass graft (CABG) surgery is a rare, potentially lethal complication, usually diagnosed at post-mortem. During the cross-clamp period of a 4-vessel coronary artery bypass graft procedure in a 74-year old hypertensive woman, retrograde dissection occurred in a diffusely diseased marginal artery when perfused with cardioplegic solution at a pressure of 140-150 mmHg through a vein graft. The dissection extended back to the left main artery, included the posterior proximal ascending aorta and then down the left anterior descending artery (LAD). Transoesophageal echocardiography (TOE) confirmed the left main dissection and showed anterior-septal-lateral akinesis in a previously normally functioning left ventricle (LV). The circumferentially calcified proximal LAD was grafted with a saphenous vein by carving an oval area of calcium creating an elliptical opening in the artery wall. Normal LV function returned and, in the area of the left main dissection, there was only thickening with no colour flow. Eight months postoperatively cardiac catheterization showed normal LV function, patent vein grafts to the right coronary artery and proximal LAD, left internal mammary artery to distal LAD and an occluded sequential marginal vein graft. Twelve years postoperatively, the patient is well with Class I angina, on medication. There is no previous documentation of a diagnosed and successfully treated left main dissection during CABG surgery. Since this case using the technique of creating an oval opening in a circumferentially calcified coronary artery (with an otherwise satisfactory lumen), the author has been using this technique to bypass otherwise non-bypassable arteries; this technique may be useful to help patients with severe calcific coronary artery disease.

Registry data evaluating the effectiveness of drug-eluting stents for the treatment of symptomatic in-stent restenosis.

BACKGROUND: In this new-era of drug-eluting stents (DES) the impact of symptomatic in-stent restenosis (ISR) is diminishing. However, world wide bare-metal stents remain widely used and therefore, it is imperative to establish a simple and effective form of treatment. The objective of this registry database was to evaluate the 'real-world' effectiveness of DES for the treatment of symptomatic bare-metal stent ISR. METHODS: All patients presenting with symptomatic ISR were evaluated between February 2003 and February 2005. Patients had 9-month angiographic follow-up with primary endpoint evaluation of binary restenosis (>50%). Secondary endpoints included in-segment late loss, target lesion revascularization (TLR) and the difference in late loss between sirolimus (n=23) and paciltaxel (n=36) eluting stents. RESULTS: Fifty eight patients with fifty nine ISR lesions were evaluated, 36% of patients had diabetes mellitus. All procedures were performed safely with no adverse peri-procedural events documented. At 9-month follow-up the median in-segment late loss was 0.24 mm (IQR 0.1, 0.53), with a binary restenosis rate of 17%. At long-term follow-up greater than 1 year, the incidence of TLR was 10%. No difference in the angiographic parameter of in-segment late loss was seen between the sirolimus and paclitaxel-eluting stents. CONCLUSIONS: In this cohort of patients with long-term angiographic and clinical follow-up, DES is an effective and safe treatment for symptomatic bare-metal stent ISR.